General practitioner Appraisals

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Tips for sessional GPs

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Our appraisal and revalidation survey conveyed that many sessional GPs require support with the appraisal and revalidation process, particularly with gathering appropriate supporting information on quality improvement activity and significant events, and collecting feedback from both colleagues and patients.

In response, we have outlined some potential solutions aimed at making appraisal and revalidation a more manageable and positive process. We have also fed into the process of successive updates to RCGP guidance to ensure that it remains fair and feasible for sessional GPs.

 

  • RCGP guidance

    The latest revision of the RCGP guidance recognises that appraisal has become more onerous than intended with regional variation and inconsistency. The revisions aim to ensure that the effort to engage in appraisal does not become disproportionate in a way that detracts from patient care.

    The RCGP guidance on supporting information guides appraisers to retain 'a supportive and developmental focus on quality maintenance and improvement through your personal and professional development without a major increase in workload'.

    This guide should be read in conjunction with our general appraisal and revalidation guidance.

     

  • Full scope of work

    Many sessional GPs have several portfolios and you will need to consider how you might evidence your fitness to practice in these different roles. If you undergo a performance review in these roles, you should include the outputs of such meetings as additional supporting information.

    In roles that are less formalised you should be able to demonstrate that your CPD and review of your practice (through quality improvement, SEAs and feedback) is drawn from the whole of the scope of your practice over the five-year revalidation cycle, with annual reflection on your competence for each role.

    For roles using specific clinical skills such as minor surgery, joint injections, cervical smears and IUCD/IUS insertions, you might have evidence of skills maintenance and refresher training, but the RCGP suggests it may be appropriate to maintain a log of personal outcome data and reflect on the outcomes.

     

    Evidence of fitness to practice

    'Any separate role which requires a licence to practise, paid or unpaid, for a different organisation, employer, or as an individual, needs to be included so that the responsible officer (RO) knows where to seek assurance that you are fit to practise.' 

    RCGP guidance

    Remember that even where your GP role is a small part of your work (eg one session per week) your responsible officer (RO) still needs evidence and reflection that demonstrates that you are up to date and fit to practice as a GP. This means ensuring that there is supporting information relevant to and drawn from your GP role(s).

    For example, if your time commitment is 80% in emergency medicine and 20% in general practice, you still need to ensure you submit evidence of quality improvement activity and significant event analysis (SEA) from general practice, not just emergency medicine. Surveys of colleagues should also include feedback from those across all of your roles, though GMC-compliant survey tools need only be used for feedback from clinical colleagues, and from patients; other tools are acceptable for non-clinical roles.

    You should include the contact details, where applicable, for each organisation or employer. This will allow the RO to confirm that there are no outstanding clinical governance issues, concerns or investigations, and will permit them to obtain an up-to-date status report on any progress made, before making your revalidation recommendation.

     

  • 1. Continuing professional development (CPD)

    You are responsible for keeping up to date through CPD which covers the whole scope of your practice. In your appraisal the RCGP recommends that you demonstrate engagement with at least 50 CPD credits, on average, per twelve months of work, irrespective of the number of sessions worked. The number of credits expected at an appraisal following a career break (such as maternity or sickness) are adjusted to reflect the time spent in work (proportional to the appraisal year).

    The previous option to double the credits claimed for each hour of CPD has been phased out from 31 March 2016, however the guidance encourages GPs to claim CPD credits for reflection on impact from learning arising from QIAs, feedback, SEAs, complaints and compliments.

     

    Keep evidence of your CPD

    One credit is 'one hour of learning activity demonstrated by a reflective note on the lessons learned and any changes made.' 

    RCGP guidance

    The RCGP recommends that GPs keep a structured learning log ('including date, title, time taken, key lessons learned and reflection on impact on practice or any changes made as a result of learning') as evidence and discourages the additional effort that many GPs currently spend on uploading certificates except where these pertain to ‘mandatory’ training defined by the employing or contracting organisation.

    You will be expected to show a range of learning methods over a five year cycle. The latest RCGP guidance emphasises the importance of learning with colleagues outside of your place of work. For sessional GPs, participation in learning groups (also known as CPD groups) are a good example of this, alongside formal taught courses, lectures or locality ‘protected learning time’ events. Where it has not been possible to meet the various recommendations for CPD a reflective note is necessary to explain this and outline plans to address this where appropriate.

     

  • 2. Quality improvement activity

    The RCGP recommends that you 'demonstrate the ability to review and learn from your medical practice by reflecting on representative quality improvement activities (QIA) relevant to your clinical work every year, with a spread of QIAs across all of your scope of work over a five year cycle'.

    In the past this has meant two SEAs each year and a clinical audit in a five year cycle. In the current RCGP guidance no fixed number of QIAs is specifically recommended. The guidance builds on the recent trend towards greater flexibility and recognises that some forms of QIA may be difficult to achieve in some circumstances, for example true peripatetic locum work.

     

    Forms of QIA

    The guidance also recommends that you should choose QIAs which are representative and appropriate to your scope of work. QIAs can take many forms such as:

    • large scale national audit
    • formal audit
    • review of personal outcome data
    • small scale data searches
    • nformation collection and analysis (Search and Do activities)
    • plan/do/study/act (PDSA) cycles
    • significant event analysis (SEA) reflective case reviews
    • outcomes of reflection on your formal patient and colleague feedback survey results, Significant Events and Complaints'.

    You are encouraged to submit good quality examples with appropriate reflection, making clear your personal involvement without the need to be involved in data collection. Where organisational, regional or national outcome data is provided you can provide a reflection on what this means about your personal performance and your response or actions.

    Where you employ specific clinical skills such as minor surgery, joint injections, cervical smears and IUCD/IUS insertions, a log of personal outcome data with reflection would be a suitable example.

     

    Clinical audit and review exercises

    Clinical audit, although an established tool for systems quality improvement, has long been an area that many sessional GPs can find problematic because of their limited influence over practice systems, lack of support with searches, and lack of managerial influence, as well as problems accessing records when working peripatetically. For this reason it is accepted that clinical audit may not always be feasible or relevant to the sessional GP's role or responsibilities.

    Sessional GPs may appropriately focus quality improvement efforts on areas of personal practice for example:

    • record-keeping 
    • referrals or investigations 
    • prospective case based condition reviews 
    • random case analysis or review of telephone triage outcomes 
    • prescribing

    Ideally you need to demonstrate change in your practice linked to learning points arising from these review exercises. Case reviews are one way to demonstrate that such changes are subsequently incorporated into practice. You should aim to document these using a suitable structured template which incorporates reflection and learning points.

     

  • 3. Significant events

    This is an area where the latest RCGP guidance (2016) has slightly changed. It is important to understand the difference between 'GMC level' significant event analyses (SEAs; also known as serious untoward incident or significant event audits) and those SEAs routinely undertaken in primary care. The former (GMC level SEAs) refer to incidents where significant harm could have or did come to a patient or patients. Most GPs will not have a serious untoward incident to report and should make a declaration to this effect at the appraisal.

    The GMC consider the type of SEA routinely undertaken in primary care to be a quality improvement activity (QIA) and these can be submitted as an example of QIA and there is no longer any minimum number of these to be submitted each year.

    The difference between GMC level SEAs and other SEAs is also clarified in the RCGP SEA toolkit.

    You must however declare all GMC level SEAs in which you have been personally named or involved. You will need to include an analysis of each of these using a standard pro-forma after discussion with colleagues including reflections and actions going forward.

    You also need to demonstrate your awareness of how SEs are captured (and how you would report them) in the organisations within which you work, across the whole of your scope of work.

    GP significant events are normally discussed at practice meetings, however where sessional GPs are not invited to participate in these (contrary to best practice and GPC recommendations) it is acceptable to discuss significant events in a practitioner group or self-directed learning group. Where this is not possible the event can be discussed during the appraisal meeting itself after appropriate reflection on a suitable template.

     

  • 4. Patient feedback

    Patient feedback is a GMC requirement and presents challenges for many sessional GPs, especially locums. However, the following tips should help:

    • Experience has shown that completion of patient surveys often takes longer than expected and patient response rates, particularly for locum GPs, are lower than average. It may be necessary to sample over a range of practices. For these reasons it is worth planning several months ahead, particularly if this is your last appraisal before revalidation.
    • You need to use a tool which complies with GMC guidance but the RCGP no longer specifies which tool you should use.
    • It is best practice to ask practice staff to distribute and collect questionnaires, something which locum GPs may wish to include in their locum agreement with the practice. Where this is not possible locums may have to do this without help. Locums who do this may wish to consider a deposit box for the completed questionnaires, as GMC guidance recommends that you do not have access to individual completed responses, with analyses being carried out by the questionnaire provider or an independent third party. Further information about this is provided in the GMC's guidance on questionnaires.
    • It is known from GMC pilots that patient satisfaction ratings are higher for doctors classed as the 'usual doctor: a feature which can disadvantage locum GPs. If you are a locum it is therefore important to choose a questionnaire provider which has locum specific benchmarks (and several do). This will make the results more relevant and meaningful to you.
    • Prison GPs will also face particular challenges in gaining patient feedback, as shown by the RCGP secure environments revalidation pilot.
    • Doctors working in an out of hours (OOH) centre where the predominant consultation method is telephone consultations or home visits may not be able to use the more widely available tools and so should be able to expect appropriate flexibility from their appraiser, appraisal lead and RO who should be able to advise on suitable alternatives as they evolve. Some OOH providers collect individual performance data and provide feedback which may be available for use in the appraisal.

     

  • 5. Colleague feedback

    Colleague feedback can also present challenges, and this is especially true for locum GPs who, due to the peripatetic nature of their work and frequently not able to participate in team meetings, can have much more limited contact with colleagues at any one time.

    Things to remember:

    • Experience has shown that completion of colleague surveys often takes longer than expected. This is because it takes time for colleagues to get to know you and you may need to collect feedback across several practices as you rotate through them. You may need to ask your survey provider to extend the response period to several months to allow you to collect feedback (and the relevant number of responses) over a longer period of time. An important part of the process is filling in your own self-assessment forms as part of the colleague and patient surveys, so allow yourself adequate time to do this.
    • You need to ensure that the feedback includes colleagues from all your roles (ie the whole scope of practice), however the RCGP guidance now offers greater flexibility over the choice of survey tool. For clinical colleagues you can choose any GMC compliant tool, however for non-clinical colleagues you can choose from a wider range to select the most useful tool for that non-clinical role.
    • If you are a locum GP, you should consider a GMC compliant clinical survey tool that has locum-specific benchmarks (such as locums, out of hours doctors, and similar).
    • You will need to reflect on the results of both the patient and colleague survey, ideally using one of the structured forms provided as part of the survey tool, and you will need to consider what learning needs have arisen when you come to agree your Personal Development Plan (PDP).
    • The latest RCGP guidance suggest that you reflect on some of the many other sources of feedback from your patients, including compliments, annually at your appraisal as patient groups have raised concern that a formal survey on a five yearly basis does not provide a sufficient 'patient voice'. Informal comments can be captured and submitted accompanied by adequate reflection remembering to ensure that submissions must not include patient identifiable data.

     

  • 6. Review of complaints and compliments

    Feedback is often provided by patients (and others) by way of complaints and compliments – this should also be reviewed as part of the appraisal process.

    Things to remember:

    • A complaint is 'a formal expression of dissatisfaction or grievance. It can be about an individual doctor, the team or about the care of patients where a doctor could be expected to have had influence or responsibility.'
    • Complaints should be considered as another type of feedback, allowing you to review and further develop your practice and to make improvements. The RCGP revalidation guide provides an outline of the elements to be covered when considering complaints.
    • As with significant events, complaints are normally discussed at practice meetings. Sessional GPs may not be invited to participate in these. Nevertheless, as part of this process a practice should inform the sessional GPs of a complaint directed at them and invite the sessional GP to take part in such discussions. It is therefore important that you highlight in your terms of engagement the need to be informed promptly about complaints or concerns and the importance of having the opportunity to respond to these. Read our guidance on locum GP agreements
    • As GPs we tend to concentrate on complaints and not on the compliments we receive. You should bring any compliments you have received to the appraisal, as these are just as important.

    Other items

    You may be asked by your responsible officer to bring specific information to the appraisal, such as routine clinical governance information provided by your organisation, or the outcomes of an investigation or complaint. It is important to comply with such requests to ensure that you share your reflections on these items with your appraiser, and this can be captured in appraisal summary.

     

  • Further information

    Choice of appraiser

    You should be able to access a pool of trained and quality assured appraisers who understand your role. The NHS appraisal policy for England is now based on allocation rather than choice, with the opportunity to appeal an allocation.

     

    Taking a career break

    If you are taking a career break or considering doing so, read our guidance on taking a career break, which includes information about the impact on your revalidation and appraisal.

     

    If any of the problems detailed above affect you

    Remember to consult local processes for allocation, appeals and complaints if you have concerns. Remember also that completing feedback about your appraiser is important to the quality assurance of the appraisal system in your area.

    You should seek advice from your appraisal lead and RO (in writing) early on in your appraisal cycle. If you are concerned about the response you receive you should contact the BMA for further support.

     

    Sources of support

    Sessional GPs often experience professional isolation which can have an adverse impact on CPD, career development opportunities, morale and can make appraisal and revalidation more challenging.

    If you find yourself in this situation, because for example you are new to an area or newly qualified, you may find one of the following helpful:

    • Your Local Education and Training Board or Deanery as they may have tutors with a special interest in sessional GP
    • Your local sessional GP group
    • Local self-directed learning groups also known as CPD groups. The above contacts may be able to signpost you to these
    • Your First5 RCGP group
    • Local Chambers

     

  • Useful resources

    This guide should be read in conjunction with the BMA’s general appraisal and revalidation guidance, with further useful resources as below: